Nutritional Needs in Children with AKI: Understanding Renal Support
Children with Acute Kidney Injury (AKI) face unique challenges, including stress response, altered nutrient utilization, and potential malnutrition. Exploring the impact of AKI on energy expenditure and substrate utilization can guide effective nutrition prescriptions for pediatric patients.
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Presentation Transcript
Norma J Maxvold MD Associate Professor of Pediatrics Pediatric Critical Care Medicine Children s Hospital of Richmond Virginia Commonwealth University
Objectives: Overview Nutritional Needs in Children with AKI Effect of renal support on Nutrition Diagram of Nutrition Prescription during AKI
Acute Illness: Stress Response AKI Acidosis, Uremia, Impaired AA Conversion, Lipid Oxidation Cytokines, Hormonal changes, Altered Substrate Utilization CATABOLIC, HYPERMETABOLIC CATABOLIC, HYPERMETABOLIC STATE STATE Malnutrition Malnutrition
Decreased physical activity, decreased insensible losses, and transient absence of growth during the acute illness may reduce energy expenditure Pediatric patients may not exhibit significant hypermetabolism post-injury? Mehta, N. and Duggan, C. (2009); Mehta, N. et al. (2009); Hardy Framson et al. (2007); Vasquez Martinez et al. (2004); Hardy et al. (2002); Briassoulis et al. (2000); Letton et al. (1995), Agus and Jaksic (2002)
Substrate Utilization/Nutrient Composition 75%CHO:15% AA: 10% Lipid 15%CHO: 15%AA: 70% Lipid C13 Glucose, C13 Acetate Maximum Glu Oxidation 4mg/kg/min Lipogenesis from Excess Glucose Metabolism Gluconeogenesis and Protein Catabolism was not effected [Tappy et al. Crit Care Med 1998;26:860-867]
AveEnergy Intake REE Coss-Bu( Am J Clin Nutr 2001) 0.23 MJ/kg/d >25% Verhoeven(Int Care Med 1998) 0.24 MJ/kg/d >14% Joosten (Nutrition 1999) 0.26 MJ/kg/d >20%
IC: measure resting energy expenditure. Based on: Expired CO2 and O2 (O2 consumption + CO2 production). Potential problem with CRRT May affect IC measurements. HCO3/CO2 fluxes IC may not be reliable? Hemofilter Effluent Dialysis fluid
Energy and Substrate Use in Acute Illness in Children Coss-Bu et al Am J Clin Nutr 2001;74:664 Normal Metabolic : Hypermetabolic mREE 0.16 mREE 0.28 Fat Oxidation -22mg/min Fat Oxidation 27mg/min np RQ 1.21 npRQ 0.86 Energy Intake: 0.25MJ/kg/d [55kcal/kg/d] CHO: 10 g/kg/d ; Fat: 1.4g/kg/d; Protein:2.1g/kg/d
No Growth occurs during Acute Illness No Growth occurs during Acute Illness Focus : Prevent Malnutrition High basal rate of metabolism Limited reserves Baseline poor nutrition + Uremia and acidosis Altered renal Amino Acid metabolism, lipid metabolism, Fluid and Solute Clearance, + Losses for Renal Replacement Therapy Children at Risk:
UNA / PCR in Acute Kidney Injury Adult Studies: Protein Catabolic Rate ~ 1.4 - 1.7 g/kg/d [Macias WL, et al. JPEN 1996;20:56-62] [Chima CS, et al. JASN 1993; 3:1516-1521] Pediatric Studies: Urea Nitrogen Appearance UNA ~ 185- 290mg/kg/d (PCR 1.1- 1.8 g/kg/d) [ Kuttnig M, et al. Child Nephrol Urol 1991;11:74-78] [ Maxvold N, et al. Crit Care Med 2000;28:1161-1165]
CALORIC SUPPORT: PROTEIN SUPPORT: Adult: Adult: npkcal 25kcal/kg/d CHO 5 g/kg/d Fat 0.8-1.2g/kg/d Protein 1.5-2.0 g/kg/d Pediatric: Protein 2.0-3.0 g/kg/d Pediatric: Npkcal 40-65kcal/kg/d ( Cano N et al Clin Nutr 2006 and 2008)
Can Nitrogen Balance be Achieved in AKI patients on CRRT? Conflicting Studies Bellomo et al Ren Fail 1997 Protein Intake : Nitrogen Balance 1.2 g/kg/d AA -5.5 g N /d 2.5 g/kg/d AA -1.9 g N /d
Scheinkestel et al. 1. Nutrition, 2003 In 11 critically ill adults on CRRT, protein intake 2.5 g/kg/day led to a) normal amino acid levels and b) positive nitrogen balance. Potential for losses during CRRT 2. Nutrition, 2003 50 critically ill adults on CRRT: 1.5 vs 2.0 vs 2.5 g/kg/day. NB related to protein intake. NB related to hospital stay Protein intake 2.5 g/kg/d: improved survival!
60 50 40 K 30 ml/min/1.73m2 20 10 0 Thr Glu Gln Pro Gly Ala Val Met Phe Lys His Arg Amino Acids
[Ziegler et al, Ann Intern Med 1992;116:821] 45 BMT patients with Parenteral Glutamine (L-Gln) Supplemention : 0.57g/kg/d Gln &2.07g/kg/d AA Intake Improved Nitrogen Balance: -1.4g/d vs -4.2g/d Clinical infections: 3/24 vs 9/21 Hospital stay: 29 days vs 36 days [ Schloerb et al; JPEN 1993; 17:407-413] Hospital stay: 26 days vs 32 days Total Body Water: -1.2 L vs 2.2 L (Bioimpedance)
Lipid Metabolism Fatty Acid Utilization during acute illness Mitochondrial adaptation to acute stress (Carnitine dependent enzymes) Calvani et al Basic Res Cardiol 2000 Mitochondrial control of FFA oxidation and CHO oxidation AcetylCoA/ CoA ratio on PDH Complex
Advantages: Lower Linoleic concentration MCT rapidly cleared from plasma Olive oil less prone to peroxidation Fish oil beneficial anti-inflammatory Early Studies : Good Safety profile Clin Nutr 2013;32:224 JPEN 2012; 36:81S
Water Soluble Vitamins Vit B1 Def Altered Energy Metabolism, Lactic Acid, Tubular damage Vit B6 Def Altered Amino acid and lipid metabolism Folate Def Anemia Vit C Def Limit 200 mg/d as precursor to Oxalic acid
Nutritional parameter Nutrition modality - Early enteral feeding, may require parenteral nutrition suppl 35 to 60 kcal/kg/day (0.15-0.27 MJ/kg/day) 20 to 25% as carbohydrates (insulin as needed), 4-5 mg/kg/min Glucose support (Insulin as needed for Hyperglycemia) Energy 2 to 3 g/kg/day with AKI (Increase intake if on High flow CRRT (by 20%) Protein Daily recommended intake ( replacement ) Monitor serum folate, water soluble vitamin levels Vitamins Trace elements Daily Recommended Intake MEE, Nitrogen Balance, Electrolytes, Vitamins, Trace elements Monitoring Glutamine, Carnitine Supplement Consider
